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err �1��.�•-(f z z4fi.� ���j 7a.vt�.#� <br /> SAN JOACUIf) ITY PUBLIC HEALTH SERVICES/EN 1RONMENTAL I/1 I DIVISIONr � ( <br /> I, -�UGST WORKSHEET FOR SITE CLOSURE EVALUATION r ATE <br /> J . e ,q(1 <br /> FAME OF FACILITY � � 1rod��ts EEPS CODE rZ <br /> DDRE55 { Was VL I ktcl <br /> ANK ID # 3�- f Z7 7-03 i <br /> AHK SIZE 5 � UEL TYPE L <br /> 11. GENERAL SITE HISTORY <br /> w* <br /> Is hermit current? eS o ermit # ac Lity Status Code �, oo.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) n.�: ype of Tank feel brgl ngt Dual <br /> 1 I I. TANK HISTORY r" F h+tidJ 2Gt 11.VL ,qD <br /> 'as Tank tested? IYes I VNo I ailed precision test ? IYes o I If yes, give date(s) <br /> Jas a repair made to the tank system? es No 11f yes, what was r4 iredd <br /> ss repair done under inspection? es o ere soil samples anal zedl es TXf H-G PH-O b/EDB <br /> rpe of faiture/discharge atastrophic long-term Leak loverf ll Elfno!n then: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es a epth to Ground Water IU of/Year 3(0 verage Annual Precipitation <br /> Site Well(s) IYes I o I r & Type Err on Lb <br /> S care S Score 5 Score <br /> istance to Wett(s) from Tank ft; ft; ft C 0 pts C 9 pts C 5 pts <br /> 0 f 0 if 0 if <br /> R ondition R condition R ondition <br /> i. Site Feature - Leaching Potential Analysis E s met E is met E is met <br /> 13 inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 O 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Gt Unknown' resent <br /> verage Annual Precipitation (inches) xxxxx X10 9 10-25 gxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration r <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown 31resent <br /> inique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> .p(.a5 hit <br /> COLUMN TOTALS»,*TOTAL POINTS + Z ' E5 <br /> 3 - <br /> mole Result: (D T X OR E) RANGE OF TOTAL POINTS119 pts or more 41 - 48 pts 40 pts or Less <br /> B/E; - tjov 5pPb <br /> N. -�. • OIL,pem B T X E B T X E <br /> )C . 13 12p,ti MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 3 3 1. 1. NA\3 <br /> Sample Result: SOLINE 1000 100 10 <br /> � <br /> �n AXIMUH ALLOWABLE TPH LEVELS (PPM).2 2F`� TPH iESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented sci€ and/or ground water contaminatiom is present, do not complete the leaching potential <br /> analysis. (i.e., site is currentty on UGT Comramination List for soil or ground water.) <br /> \1 if depth is � 5 ft. and < 25 ft., score 0 points-. I depth ­5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not appticabte at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION rj5an, .D 1 Tal OH3jopm XY LA-*4- - <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes y a I CL,,, V, :,- 2 CC)vl+,C n l � <br /> 2. Recommend Site Closure 1Yes o If Yes, Refer to Site Mit gation for Evaluation � � <br /> .'TI. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> -CHCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES IO <br /> ATE REFERRED / / ATE CLOSURE LETTER MA1LE <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />